Report shows management of CMS payment program shows vulnerabilities

While CMS has made some progress towards addressing problems with the Quality Payment Program (QPP), a new report shows vulnerabilities remain regarding technical assistance for clinicians and the potential for fraud and improper payments. The HHS Office of the Inspector General (OIG) report noted that if CMS fails to sufficiently address these issues, clinicians may struggle to success under the QPP or choose not to participate. The report also found that CMS needs to put systems in place to effectively prevent, detect, and address fraud and improper payments.

CMS is implementing core provisions of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) (P.L. 114-10) as the QPP, a set of clinician payment reforms designed to put increased focus on the quality and value of care. The QPP is a significant shift in how Medicare calculates payment for clinicians and requires CMS to develop a complex system for measuring, reporting, and scoring the value and quality of care.

Technical assistance

The report shows that if clinicians do not receive sufficient technical assistance, they may struggle to succeed under the QPP or choose not to participate. Clinician feedback collected by CMS demonstrates widespread basic awareness of the QPP, but also indicates uncertainty regarding details of participation such as who must report and how to submit data. CMS contractors have focused largely on general education initiatives, with fewer resources devoted to more customized, practice-specific technical assistance. CMS has established a Service Center to answer questions about the QPP by phone or email. Service Center data indicate that clinicians continue to have questions about both eligibility and scoring criteria, and that small practices, in particular, need information and assistance. Small practices and clinicians in rural or medically underserved areas, who may have fewer administrative resources and less experience with prior CMS quality programs, should be prioritized for assistance. The report stated, “Clinician feedback collected by CMS demonstrates widespread awareness of the QPP, but also uncertainty about eligibility, data submission, and other key elements of the program.”

Fraud

The report also found that if CMS does not develop and implement a comprehensive QPP program integrity plan, the program will be at greater risk of fraud and improper payments. To ensure that the QPP succeeds, CMS must effectively prevent, detect, and address fraud and improper payments. QPP payment adjustments are intended to reward high-value, high-quality care. Safeguarding the validity of Merit-based Incentive Payment System (MIPS) data and the accuracy of QPP payment adjustments is critical to ensure that these payments are based on clinicians’ actual performance. Appropriate oversight is critical to prevent fraud and improper payment adjustments. CMS needs to clearly designate leadership responsibility for QPP program integrity. CMS also needs to develop a comprehensive program-integrity plan for the GPP to ensure the accuracy of MIPS data submitted by clinicians. CMS said that it “is currently in the early stages of developing an oversight plan to QPP data.”

All Medicare stakeholders need to know MACRA

Although the Medicare Access and CHIP Reauthorization Act (MACRA) (P.L. 114-10) is best known for changing Medicare provider payments, its true goal is improving the quality of care delivery across the health spectrum. As a result, according to Todd Gower and Lisa Alfieri from the Risk Transformation, Health compliance sector of EY, providers must enhance their relationships and contracts with providers. Gower and Alfieri, speaking at a Health Care Compliance Association (HCCA) webinar titled “MACRA: Not just for Providers,” explained that having the proper infrastructure to obtain and organize all necessary documentation is the key to surviving MACRA.

Gower and Alfieri stressed the need for new discussions within health systems, noting that MACRA has potential to transform the health care system “equally, if not far more” than the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148). As it implements MACRA, HHS is having new conversations with stakeholders including whether the shared risk will actually improve care, and whether the current proposed criteria (see Halfway through QPP ‘transition year,’ CMS proposes substantial changes , June 21, 2017) are too restrictive. They praised HHS’ website on the Quality Payment Program as a new way to communicate with providers and other stakeholders.

MACRA is a complex law with wide-reaching repercussions. Gower and Alfieri suggested infrastructure updates, and predicted that the most-advanced providers will be seeking commercial payer partners by 2019 to maximize incentives for value-based care (VBC) payment models. Therefore, payers should create or enhance existing VBC offerings now to meet that expected need. MACRA steering committees are important to ensure compliance and update risk management programs for providers, but also for non-provider groups.

AMA provides resources to help physicians with MIPS reporting

As part of its effort to improve Medicare Payment Reform, the American Medical Association (AMA) is providing tools for physicians to better understand and meet the reporting requirements under the new Quality Payment Program from CMS. The AMA has created a “One Patient, One Measure, No Penalty” campaign to help physicians understand the reporting requirements and avoid the 4 percent penalty for not reporting under the Merit-Based Incentive Payment System (MIPS) track. Along with this campaign, the AMA has created an interactive MIPS Action Plan that provides deadlines and a step-by-step plan of how to meet the reporting requirement deadlines.

As part of the “One Patient, One Measure, No Penalty” campaign, the AMA has provided a short video that demonstrates how to fill out CMS forms to accurately report a quality measure on a patient encounter. A step-by-step guide is also provided as a supplement to the video, along with a sample form to review. There are also links to other tools, such as the CMS Quality Measure Search tool, so that all of the resources are available in one easy-to-find location.

The MIPS Action Plan is a ten-step plan that begins with a determination of whether MIPS applies to the physician. The AMA provides a detailed breakdown of some of the determining factors, such as whether a physician is considered a hospital-based physician, in a frequently asked questions supplemental resource. The MIPS Action Plan then proceeds to walk through the process of reporting, including deadlines to start reporting, and submitting 2017 MIPS data.

Wait! Physicians are not ready for the QPP

Physicians expressed concern over their knowledge of and preparedness for Medicare’s Quality Payment Program (QPP) in a recent American Medical Association (AMA) and KPMG consulting survey. Only 10 percent of responding physicians expressed feeling deeply knowledgeable about the Medicare Access and Chip Reauthorization Act (MACRA) (P.L. 114-10) or the QPP and 90 percent of respondents indicated that they find the requirements of MACRA’s merit based incentive payment system (MIPS) to be slightly or very burdensome.

QPP

MACRA created the QPP, which, in January 2017, began marking the quality performance of physicians. In 2019, the program will make adjustments to physician payments under one of two tracks: (1) MIPS or (2) a 5 percent lump sum bonus payment if the physician has a threshold percentage of patients or revenue in an advanced alternative payment model (Advanced APM). Because little is known about physician preparation under the program, the AMA and KPMG conducted a survey to gauge physician readiness and knowledge. The survey of 1000 physicians was conducted between April 25 and May 1, 2017, prior to proposed updates to the QPP program released on June 30, 2017 (see Halfway through QPP ‘transition year,’ CMS proposes substantial changes, June 30, 2017).

Findings 

Only 51 percent of physicians expressed feeling somewhat knowledgeable about MACRA and the QPP. Seven in 10 respondents have begun preparation for QPP in 2017, however, of those respondents preparing for MIPS in 2018, only 65 percent reported feeling prepared. The vast majority of respondents—90 percent—indicated that they found MIPS’ requirements burdensome. The cause of that burden, for most respondents, was the time and cost associated with reporting. Physicians expressed specific concerns regarding the unknown financial ramifications of the program, with only 8 percent of respondents indicating they were very prepared for long-term financial success under the program.

Impact

The AMA and KPMG survey concluded that some impacts—time and complexity of reporting—impact physicians regardless of practice size, specialty, or previous reporting experience. Additionally, physicians across practice areas agree that long-term financial impacts remain uncertain and that the program would benefit from more APMs.